Common ICD-10 Documentation Deficienciesruralhealth.med.uky.edu/sites/default/files/KORH...Common ICD-10 Documentation Deficiencies Sharon Shover, CPC, CEMC [email protected]

CommonICD-10DocumentationDeficiencies

SharonShover,CPC,[email protected]

Agenda

ChapterSpecificCodingGuidelines:• Chapter1:InfectiousandParasiticDiseases(A00-B99)• Chapter2:Neoplasms(C00-D49)• Chapter3:DiseasesofBloodandBloodFormingOrgans(D50-D89)• Chapter4:Endocrine,NutritionalandMetabolicDiseases(E00-E89)

• Diabetes(E08-E13)• Chapter5:MentalandBehavioralDisorders(F01-F99)• Chapter6:DiseasesoftheNervousSystemandSenseOrgans(G00-G99)• Chapter7:DiseasesoftheEyeandAdnexa(H00-H59)• Chapter8:DiseasesoftheEarandMastoidProcess(H60-H95)• Chapter9:DiseasesoftheCirculatorySystemandSenseOrgans(I00-I99)

• Hypertension(I10-I15),RO3.0forelevatedBP(ICD-9code796.2)• Chapter10:DiseasesoftheRespiratorySystem(J00-J99)• Chapter11:DiseasesoftheDigestiveSystem(K00-K94)• Chapter12:DiseasesoftheSkinandSubcutaneousTissue(L00-L99)• Chapter13:DiseasesoftheMusculoskeletalSystemandConnectiveTissue

(M00-M99)

Agenda

• Chapter14:DiseaseoftheGenitourinarySystem(N00-N99)• Chapter15:Pregnancy,Childbirth,Puerperium(O00-O9A)

• OB,deliveryandpostpartumservices• Chapter16:Newborn(Perinatal)Guidelines(P00-P96)

• Newbornservicesandreportingstillborn• Chapter17:CongenitalMalformations,DeformationsandChromosomal

Abnormalities(Q00-Q99)• Chapter18:Systems,SignsandAbnormalClinicalandLaboratoryFindings,Not

ElsewhereClassified(R00-R99)• Codesthatdescribesymptomsandsignsthatareacceptableforreporting

purposesandwhenarelateddefinitivediagnosishasnotbeenestablished(confirmed)bytheprovider.

• Chapter19:Injury,PoisoningandCertainOtherConsequencesofExternalCauses(S00-T88)

• Chapter20:ExternalCausesofMorbidity(V01-Y99)• Chapter21:FactorsInfluencingHealthStatusandContactwithHealthServices

(Z00-Z99)

ProceduresThatRemainwithUpdatedICD-10-CM

• Reasonforfirstvisit

• Codetothehighestlevelofknownspecificity

• Donotcodefor“probable,suspectedorquestionable”

• Codechronicdiseasesaslongaspatientisstillreceivingtreatment

HierarchicalConditionCategory(HCC)Coding

• MedicareAdvantagePlans• Onceevery12months• Usuallyperformedatwellnessexam(AWV)

• Causesconfusionwhenperformedduringmedicalvisit

• Medicalnecessitybasedontreatment

ChapterSpecificGuidelines

Chapter1:InfectiousandParasiticDiseases(A00-B99)

Encounters for testing for HIV• If patient is being seen to determine his/her HIV status, use code

Z11.4, Encounter for screening for human immunodeficiencyvirus [HIV]. Use additional codes for any associated high riskbehavior.

• If patient with signs or symptoms is being seen for HIV testing,code the signs and symptoms. An additional counseling codeZ71.7, Human immunodeficiency virus [HIV] counseling, may beused if counseling is provided during the encounter for the test.

• When a patient returns to be informed of his/her HIV test resultsand the test result is negative, use code Z71.7 , Humanimmunodeficiency virus [HIV] counseling.

• If the results are positive, see previous guidelines and assigncodes as appropriate.

Chapter2:Neoplasms(C00-D49)

Currentmalignancyversuspersonalhistoryormalignancy• When a primary malignancy has been excised butfurther treatment, such as additional surgery for themalignancy, radiation therapy or chemotherapy isdirected to that site, the primary malignancy codeshould be used until treatment is completed.

Chapter4:Endocrine,NutritionalandMetabolicDiseases(E00-E89)

Diabetesmellitusandtheuseofinsulinandoralhypoglycemics• If the documentation in a medical record does notindicate the type of diabetes but does indicate thatthe patient uses insulin, code E11, Type 2 diabetesmellitus, should be assigned. Code Z79.4, Long-term(current) use of insulin, or Z79.84, Long-term(current) use of oral hypoglycemic drugs, shouldalso be assigned to indicate that the patient usesinsulin or hypoglycemic drugs.

Chapter4:Endocrine,NutritionalandMetabolicDiseases(E00-E89)

• E66– Overweightorobese• Useadditionalcodetoidentifybodymassindex(BMI),ifknown(Z68.-)• BMI,20-29,adult• BMI,30-39,adult• BMI,40orgreater,adult• BMI,pediatric

– Bypercentile

Chapter5:MentalandBehavioralDisorders(F01-F99)

PsychoactiveSubstanceUse,AbuseAndDependence• When the provider documentation refers to use, abuse and

dependence of the same substance (e.g. alcohol, opioid,cannabis, etc.), only one code should be assigned to identifythe pattern of use based on the following hierarchy:• If both use and abuse are documented, assign only the code for

abuse• If both abuse and dependence are documented, assign only

code for dependence• If use, abuse and dependence are all documented, assign only

the code for dependence• If both use and dependence are documented, assign only code

for dependence

Chapter6:DiseasesoftheNervousSystemandSenseOrgans(G00-G99)

ChronicPain• Chronic pain is classified to subcategory G89.2. Thereis no time frame defining when pain becomeschronic. The provider’s documentation should beused to guide use of these codes.

Chapter7:DiseasesoftheEyeandAdnexa(H00-H59)

AssigningGlaucomaCodes• Assign as many codes from category H40, Glaucoma,as needed to identify the type of glaucoma, theaffected eye, and the glaucoma stage.GlaucomaScale:0-Unspecified1-Midorearlystage2-Moderatestage3-Advanced,late,severeStage4-Indeterminate

Chapter9:DiseasesoftheCirculatorySystemandSenseOrgans(I00-I99)

Hypertension,Transient• Assign code R03.0, Elevated blood pressure readingwithout diagnosis of hypertension, unless patient hasan established diagnosis of hypertension.

• Assign code 013.-, Gestational [pregnancy-induced]hypertension without significant proteinuria, or 014.-,Pre-eclampsia, for transient hypertension ofpregnancy.

Chapter10:DiseasesoftheRespiratorySystem(J00-J99)

TobaccoExposure• Use additional code, where applicable, to identify:• Exposure to environmental tobacco smoke - Z77.22• Exposure to tobacco smoke in the perinatal period –P96.81

• History of tobacco dependence – Z87.891• Occupational exposure to environmental tobaccosmoke – Z57.31

• Tobacco dependence – F17.-• Tobacco use – Z272.0

Chapter12:DiseasesoftheSkinandSubcutaneousTissue(L00-L99)

Pressureulcerstages• Codes from category L89,

Pressure ulcer, identify thesite of the pressure ulcer aswell as the stage of the ulcer.

• The ICD-10-CM classifiespressure ulcer stages basedon the severity, which isdesignated by stages 1-4,unspecified stage andunstageable.

• Assign as many codes fromcategory L89 as needed toidentify all the pressureulcers the patient has, ifapplicable.

Chapter13:DiseasesoftheMusculoskeletalSystemandConnectiveTissue(M00-M99)

Osteoporosis• Osteoporosisisasystemiccondition,meaningthatallbonesofthemusculoskeletalsystemareaffected.Therefore,siteisnotacomponentofthecodesundercategoryM81Osteoporosiswithoutcurrentpathologicalfracture.

• ThesitecodesundercategoryM80,Osteoporosiswithcurrentpathologicalfracture,identifythesiteofthefracturenottheosteoporosis.

Chapter15:Pregnancy,Childbirth,Puerperium(O00-O9A)

Diabetesmellitusinpregnancy• Diabetesmellitusisasignificantcomplicatingfactorinpregnancy.Pregnantwomenwhoarediabeticshouldbeassignedacodefromcategory024,Diabetesmellitusinpregnancy,childbirthandthepuerperium,first,followedbytheappropriatediabetescode(s)(E08-E13)fromChapter4.


Alcoholuseduringpregnancy,childbirthandthepuerperium• Codes under subcategory 099.31, Alcohol usecomplicating pregnancy, childbirth and thepuerperium, should be assigned for any pregnancycase when a mother uses alcohol during thepregnancy or postpartum.


Tobaccouseduringpregnancy,childbirthandthepuerperium• Codes under subcategory 099.33, Smoking (tobacco)complicating pregnancy, childbirth and thepuerperium, should be assigned for any pregnancycase when a mother uses any type of tobaccoproduct during pregnancy or postpartum.

Chapter19:Injury,PoisoningandCertainOtherConsequencesofExternalCauses(S00-T88)

Applicationof7th CharactersinChapter19• 7th Character“A”

Initial encounter is used for each encounterwhere the patient is receiving active treatmentfor the condition.


Applicationof7th CharactersinChapter19th

• 7th Character“D”Subsequent encounter is used for encountersafter the patient has completed active treatmentof the condition and is receiving routine care forthe condition during the healing or recoveryphase• The aftercare Z-codes should not be used for aftercarefor conditions such as injuries or poisonings where 7thcharacters are provided to identify subsequent care.


Applicationof7th CharactersinChapter19th• 7th Character“S”

Sequela, is for use for complications orconditions that arise as a direct result of acondition, such as scar formation after a burn.The scars are a sequela of the burn. When using7th character “S” it is necessary to use both theinjury code that precipitated the sequela and thecode for the sequela itself. The “S” is added onlyto the injury code. The specific type of sequela issequenced first, followed by the injury code.

Chapter21:FactorsInfluencingHealthStatusandContactwithHealthServices(Z00-Z99)

Z00.0-Encounter for general adult medical examination (with or withoutabnormal findings)• Not to be used for examinations done regarding a sign or symptomZ00.1-Encounter for health exam of the newborns and routine children(with or without abnormal findings)• If examination is done strictly for administrative purposes not relating

to any specific conditions then pre-existing, chronic and history codesmay be applied

Z00.121-Encounter for routine child health examination WITHabnormal findingsZ00.129-Encounter for routine child health examinationWITHOUT abnormal findings


Z01.41-AnnualGYNexam(withorwithoutabnormalfindings)

Z01.411-EncounterforGYN(exam)(routine)WITHabnormalfindingsZ01.419-EncounterforGYN(exam)(routine)WITHOUTabnormalfindingsZ01.42-Encounterforcervicalsmeartoconfirmfindingsofrecentnormalsmearfollowinginitialabnormalsmear

• Ifencounteriscodedwhiletestresultsareoutstandingitisacceptabletocodefor“withoutabnormalfindings”


Z01.20-.21 - Encounters fordental exam and cleaning (withor without abnormal findings)

Z01.8 - Encounters for pre-procedural exams for cardio,respiratory, lab, allergy, bloodtyping, antibody responses


Z02-Z04-EncountersforadministrativeexamsZ02.5-SportsphysicalZ02.71-DisabilityexamsZ04.71andZ04.72-Examsfollowingallegedadultorchildabuse

Z11-Encounterforscreeningforinfectiousandparasiticdisease

Z11.3-EncounterforscreeningforinfectionwithpredominatelysexualmodeoftransmissionZ11.4-EncounterforHIVZ11.59-Encounterforotherviraldisease


Z13-Encounter for screening for other disease anddisorder

Z13.6-Encounter for screening for cardiovasculardisorder

Z23-Encounter for Immunization• Code first any routine childhood examinations

Z28-Immunization not carried out and underimmunization status


Z30-ContraceptivemanagementZ30.42-EncoutnerforsurveillanceofinjectablecontraceptivesZ30.49-Encounterforsurveillanceofothercontraceptives

• Codesusedtoidentifyinitialprescriptionaswellasongoingsurveillance

• Optionsincludepills,injectableorIUD’s

Z32-Encounterforpregnancytest,resultsunknown

Z48-Encountersforpost-proceduralaftercareZ48.00-Change/removalofnonsurgicaldressingZ48.01-Change/removalofsurgicalwounddressingZ48.02-Encounterforremovalofsutures


Z72-ProblemsrelatedtolifestyleZ72.0-TobaccouseZ72.3-LackofexerciseZ72.4-Inappropriatedietandeatinghabits

Z73-Problems relating to life management difficultyZ79-Long-term (current) drug therapy; Includinganticoagulants, antithrombotic, NSAID, hormonalcontraceptives, insulin, steroids

Z51.81-Codeanytherapeuticdrug-levelmonitoring

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Documents

Common ICD-10 Documentation Deficienciesruralhealth.med.uky.edu/sites/default/files/KORH...Common ICD-10 Documentation Deficiencies Sharon Shover, CPC, CEMC [email protected]